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.10/16/2007 10:05 9166385611 <br />E <br />CASCADEDRILLING <br />San Joaquin County EnvikonmOntill Heafth Department Uh-d IV well Permit A <br />JOB ADDRESS" �Itec & PERMIT SR# <br />PAGE 02/02 <br />Supplement <br />LICENSED CONTRACTORS DECLARAMO (LAW <br />I hereby affirm that I am iftnied underthe provisions of Chapter 9 (commencing with sechlon 7000) of Division <br />of the Business and Proftsions Code and my license is in full force and effect, <br />License Expiration Date* <br />Data: c) 77 00 Itractor. <br />Title- <br />N:,j <br />Printed name: <br />V <br />ORRERY' Q0MPF_NSAn0N DECLARA"nON <br />I hereby affirm under penally hf perjury one of the following declarations: (CHECK ONO) <br />lhave and will me . Wain 21 cefflIkOte of 00nSent to self -insure for workers' compensation, as proulded for <br />by Section $700 of the Labor Code, for the peribmunce of Me work Forwhich this petmit is Issued. <br />I have and will maintain wDrkeW compensation hmutance, as required by Section 3700 of the Labor Code, <br />far the perfoiirwrice ofthi work for which this. permit is Issued. My workers' co'mpeniation Insuronce <br />carrier and policy numbeis am.: <br />Carrier: A, -A -22r: �JkiN Piy Iturnber.07RWS ------ <br />I certW that in the perligrinancelo Me Work lbrwhich this permit is issued, I shag not smploy any -person in <br />any manner boas to b6c6me str ct to -the votirkers' compensation lam of Calibmij. and agraeffist if I <br />t <br />should become subject til the compe on provisions of Section $700 of Me Labor Code, I Mail <br />forthwith corMly with thck6e Pr M:-ions.:-� <br />Expiration Datfll:i <br />PrI <br />rftdlName. <br />WARNING: FAILURE TO SEfiCARE W66:F6RS, z GOMPENSA . MON COVERAGE IS UNLAVIFULJAND SHALL« SUBJECir <br />AN EMPLOYER TO CRIMINAL',PENALAES AND CW FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S100.000.), IN ADDITION TO *E We OF COMPENSATION, INTEREST, ATTORNEr-S. FEES, AND DAMASES AS <br />PROVIDED FOR IN SEC7'l0k3706 00 7.!HE LA OA dODF-. <br />AUTH6RkzA,nOh FOR HER THAN C-57 SIGNING PERMIT AO, PucAnDN <br />..... _(sfgwtur& aft`. -5! Ikensed authorized representative), <br />hereby authorize (print narri.e); <br />to sign this San Joaquin 0auAyWelll P8wmltAWWfttlon my bebaff. 1—demtoodfirms auihorkftni0varidlor <br />one (I)year and is limited to the work ;6n dated On thefrOnt Page oFthis application. <br />9-"-021 MI <br />P,ItD 29-02-00I <br />6=04 - <br />